Cancer Treatment and Survivorship Statistics, 2016 PDF

CA CANCER J CLIN 2016;66:271289
Cancer Treatment and Survivorship Statistics, 2016

Kimberly D. Miller, MPH1; Rebecca L. Siegel, MPH2; Chun Chieh Lin, PhD, MBA3; Angela B. Mariotto, PhD4;
Joan L. Kramer, MD5; Julia H. Rowland, PhD6; Kevin D. Stein, PhD7; Rick Alteri, MD8; Ahmedin Jemal, DVM, PhD9
1
Epidemiologist, Surveillance and Health
Services Research, American Cancer
Society, Atlanta, GA; 2Strategic Director,
Surveillance Information, Surveillance and
Health Services Research, American
Cancer Society, Atlanta, GA; 3Director,
Health Services Research, Intramural
Research Department, American Cancer
Society, Atlanta, GA; 4Branch Chief,
Surveillance Research Program, National
Cancer Institute, Bethesda, MD; 5Assistant
Professor, Department of Hematology and
Medical Oncology, Emory University
School of Medicine, Atlanta, GA; 6Director,
Office of Cancer Survivorship, National
Cancer Institute, Bethesda, MD; 7Vice
President, Behavioral Research Center,
American Cancer Society, Atlanta, GA;
8
Medical Editor, American Cancer Society,
Atlanta, GA; 9Vice President, Surveillance
and Health Services Research, American
Cancer Society, Atlanta, GA
Corresponding author: Kimberly D. Miller,

MPH, Surveillance and Health Services
Research, American Cancer Society, 250
Williams Street NW, Atlanta, GA 303031002; kimberly.miller@cancer.org.
DISCLOSURES: The authors report no
conflicts of interest.
The findings and conclusions in this report
are those of the authors and do not
necessarily represent the official position of
the National Cancer Institute.
doi: 10.3322/caac.21349. Available online
at cacancerjournal.com
ABSTRACT: The number of cancer survivors continues to increase because of both

advances in early detection and treatment and the aging and growth of the population. For the public health community to better serve these survivors, the American
Cancer Society and the National Cancer Institute collaborate to estimate the number
of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results cancer registries. In addition, current treatment patterns for
the most prevalent cancer types are presented based on information in the National
Cancer Data Base and treatment-related side effects are briefly described. More
than 15.5 million Americans with a history of cancer were alive on January 1, 2016,
and this number is projected to reach more than 20 million by January 1, 2026. The
3 most prevalent cancers are prostate (3,306,760), colon and rectum (724,690),
and melanoma (614,460) among males and breast (3,560,570), uterine corpus
(757,190), and colon and rectum (727,350) among females. More than one-half
(56%) of survivors were diagnosed within the past 10 years, and almost one-half
(47%) are aged 70 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by
primary care providers. Although there are a growing number of tools that can assist
patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care. CA Cancer J
C 2016 American Cancer Society.
Clin 2016;66:271-289. V
Keywords: prevalence, statistics, survivorship, treatment patterns
Introduction
The number of cancer survivors continues to grow in the United States despite
overall declining incidence rates in men and stable rates in women.1 This reflects
an increasing number of new cancer diagnoses resulting from a growing and aging
population, as well as increases in cancer survival because of advances in early
detection and treatment.
The American Cancer Society collaborates with the National Cancer Institute
biennially to estimate the numbers of current and future cancer survivors to help
the public health community better serve this unique population, some of whom
must cope with long-term physical effects of treatment, as well as psychological
and socioeconomic sequelae.2 In this article, we use the term cancer survivor to
describe any person who has been diagnosed with cancer, from the time of diagnosis through the remainder of his or her life. This includes patients currently undergoing treatment and those who may have become cancer-free. Throughout this
article, the terms cancer patient and survivor are used interchangeably,
although not all people with a history of cancer identify with the term cancer
survivor. We provide estimates for the most prevalent cancers, as well as statistics
on treatment patterns and survival and issues related to survivorship.
Materials and Methods

Prevalence Estimates
Cancer prevalence as of January 1, 2016 was estimated using the Prevalence Incidence Approach Model, which calculates prevalence from cancer incidence and
survival and all-cause mortality.3 Incidence and survival were modeled by cancer
VOLUME 66 _ NUMBER 4 _ JULY/AUGUST 2016
271
type, sex, and age group using invasive malignant cases

(except urinary bladder, which included in situ cases) diagnosed from 1975 through 2012 from the 9 oldest registries
in the population-based Surveillance, Epidemiology, and
End Results (SEER) program (2014 submission data).
For specific cancer site estimates, incident cases included
the first primary for the specific cancer site between 1975
and 2012. This differs from previous prevalence projections,4,5 which only included first ever malignant primaries
and did not take into account subsequent primaries at
different sites. Total cancer prevalence was calculated as in
the previous methodology using only first ever primary
cases.
Mortality data for 1975 through 2012 were obtained
from the National Center for Health Statistics. Population
projections from 2014 through 2026 were obtained from
the US Census Bureau. Projected US incidence and mortality for 2013 to 2026 were calculated by applying 5-year
average rates for 2008 through 2012 to the respective US
population projections by age, sex, race, and year. Survival,
incidence, and all-cause mortality rates were assumed to be
constant from 2013 through 2026. For more information,
see publications by Mariotto et al.6,7
2016 Case Estimates

The method for estimating the number of new US cancer
cases in 2016 is described elsewhere.1 Briefly, the total
number of cases is estimated using a spatiotemporal model
based on incidence data from 49 states and the District of
Columbia for the years 1998 through 2012 that met the
North American Association of Central Cancer Registries
high-quality data standard for incidence. Then, the number
of new cases is temporally projected 4 years ahead using
vector autoregression. This method considers geographic
variations in sociodemographic and lifestyle factors, medical settings, and cancer screening behaviors as predictors of
incidence and also accounts for expected delays in case
reporting.
Stage at Diagnosis
Several different staging systems are used to classify cancers. In this report, the American Joint Committee on
Cancer staging system,8,9 which is commonly used in clinical settings, is used for the description of treatment patterns; whereas SEER Summary Stage, a staging system
frequently used by population-based cancer registries, is
used to describe population-based patterns of stage at
diagnosis and survival.
survival, which adjusts for normal life expectancy by comparing survival among cancer patients with that of the general
population, controlling for age, race, and sex. The SEER 18
registries were the source for 5-year survival (diagnosis years
2005-2011). Data from the 9 oldest SEER registries are
used to describe changes in survival over time. Many of these
statistics were originally published in the SEER Cancer
Statistics Review, 1975-2012.10 In addition, 1-year, 10-year,
and 15-year relative survival rates were generated for selected
sites using the National Cancer Institutes SEER*Stat software (version 8.2.1).11,12 One-year survival rates are based on
cancer patients diagnosed from 2008 to 2011, 10-year survival rates are based on diagnoses from 1999 and 2011, and
15-year survival rates are based on diagnoses from 1994 and
2011; all patients were followed through 2012.
Treatment
Cancer treatment data were analyzed from 2 sources: the
National Cancer Data Base (NCDB) and the SEER program.
NCDB
The NCDB is a hospital-based cancer registry jointly sponsored by the American Cancer Society and the American
College of Surgeons. It includes approximately 70% of all
invasive cancers in the United States from more than 1500
facilities accredited by the American College of Surgeons
Commission on Cancer (CoC).13,14 Studies have shown
that disease severity and treatment patterns in the NCDB
stratified by clinical and sociodemographic factors for common cancer types are remarkably similar to those found in
population-based registries.15,16
Treatment data are for cases diagnosed in the first 6
months of 2013 for all sites except testis, for which aggregated data from 2009 through 2013 were used because of
the relatively small number of cases. In the 2013 NCDB
data release, many common targeted therapy drugs are classified as chemotherapy. For this report, we also include
drugs classified as immunotherapy in the chemotherapy category (chemotherapy does not include hormone therapy).
For more information regarding drug classification categories, see the SEER-Rx Web site (seer.cancer.gov/tools/
seerrx). Our analysis of treatment patterns does not include
diagnostic procedures. Methods of drug delivery are not
available in the NCDB, so topical or intravesical chemotherapy cannot be distinguished from systemic chemotherapy. More information can be found on the NCDB Web
site (facs.org/cancer/ncdb).
SEER
Survival
There are 2 common measures of cancer survival: relative
survival and observed survival. In this article, we use relative
272
CA: A Cancer Journal for Clinicians
The SEER 18 registries were the source for prostate cancer

treatment patterns because data are substantially less complete in the NCDB.11 However, use of androgen-
FIGURE 1. The Estimated Number of US Cancer Survivors.

Note: Estimates for specific cancer types take into account the potential for a history of more than one cancer type.
Source: Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD.
deprivation therapy is not collected, so could not be

included.
Selected Findings: Cancer Prevalence

More than 15.5 million Americans with a history of cancer
were alive on January 1, 2016. By January 1, 2026, this
number is projected to reach 20.3 million (Fig. 1). These
estimates do not include carcinoma in situ for any cancer
except urinary bladder and do not include basal cell or squamous cell skin cancers. The 3 most prevalent cancers in
2016 are prostate (3,306,760), colon and rectum (724,690),
and melanoma (614,460) among males and breast
(3,560,570), uterine corpus (757,190), and colon and rectum (727,350) among females (Fig. 1). The distribution of
cancer prevalence by type differs from that for new cases,
reflecting differences in survival as well as age at diagnosis.
More than one-half (56%) of survivors were diagnosed
within the past 10 years (Table 1). Twenty-one percent of
female survivors were diagnosed more than 20 years ago
compared to only 13% of males. Nearly one-half (47%) are
age 70 years or older, although age distribution varies by
cancer type (Table 2). For example, the majority of prostate
cancer survivors (64%) are age 70 years or older, compared
with only one-third of melanoma survivors (Fig. 2).
Selected Cancers
Breast (female)
It is estimated that there are more than 3.5 million women
living in the United States with a history of invasive breast
cancer, and an additional 246,660 women will be diagnosed

in 2016. Seventy-five percent of breast cancer survivors
(more than 2.6 million women) are ages 60 years or older,
while 7% are younger than 50 years (Fig. 2).
Breast cancer tends to be diagnosed at a younger age
than other common cancers, with a median age at diagnosis
of 61 years compared with 70 years for lung cancer and 68
years for colorectal cancer (Fig. 3). About 19% of breast
cancers are diagnosed in women ages 30 to 49 years, and
44% occur among women who are age 65 years or older.
Treatment and survival
Surgical treatment for breast cancer involves breastconserving surgery (BCS, also known as partial mastectomy
or lumpectomy) or mastectomy. When BCS followed by
radiation to the breast is appropriately used for localized or
regional cancers, long-term survival is the same as with
mastectomy.17,18 However, some patients require mastectomy because of tumor characteristics (eg, locally advanced
stage, large or multiple tumors), because postsurgery radiation is contraindicated (eg, preexisting medical condition,
such as active connective tissue disease), or other obstacles.
Younger women (<40 years) and patients with larger and/or
more aggressive tumors are more likely to be treated with
mastectomy.19,20 BCS-eligible women are increasingly electing mastectomy for a variety of reasons, including reluctance
to undergo radiation therapy and fear of recurrence.19 The
proportion of women with nonmetastatic disease who
undergo contralateral prophylactic mastectomy has also
increased rapidly, from 5% of total mastectomies in 1998 to
30% in 2011.21
273
TABLE 1.
Estimated Number of US Cancer Survivors as of January 1, 2016, by Sex and Time Since Diagnosis
MALE AND FEMALE
MALE
FEMALE
YEARS SINCE
DIAGNOSIS
NO.
PERCENT
CUMULATIVE
PERCENT
NO.
PERCENT
CUMULATIVE
PERCENT
NO.
PERCENT
0 to <5 y
5 to <10 y
10 to <15 y
15 to <20 y
20 to <25 y
25 to <30 y
30 y
5,189,400
3,530,890
2,493,340
1,655,400
1,082,460
660,180
921,550
33
23
16
11
7
4
6
33
56
72
83
90
94
100
2,713,350
1,798,090
1,212,930
729,830
443,630
228,710
250,560
37
24
16
10
6
3
3
37
61
78
87
94
97
100
2,476,050
1,732,800
1,280,410
925,570
638,830
431,470
670,990
30
21
16
11
8
5
8
CUMULATIVE
PERCENT
30
52
67
79
86
92
100
Note: Percentages do not sum to 100% due to rounding.

Source: Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute.
Among women diagnosed with stage I or II breast cancer, 61% undergo BCS (with the majority also receiving
additional therapy) and 36% undergo mastectomy (Fig. 4).
A much smaller percentage of stage III patients undergo
BCS (21%), whereas 72% undergo mastectomy. Women
diagnosed with stage IV disease most often receive radiation and/or chemotherapy alone (48%). Among women
with hormone-receptor positive breast cancer of any stage,
79% receive hormonal therapy.14
Breast reconstruction for women who undergo mastectomy may involve the use of a saline or silicone implant, a tissue flap, or a combination thereof. Although reported rates
of breast reconstruction in the United States vary widely, a
recent large study found that the 57% of women with nonmetastatic disease who received mastectomies underwent
reconstructive procedures.21 Women who undergo bilateral
mastectomy, are unmarried, or who have higher education or
income are more likely to undergo reconstruction.22
The overall 5-year relative survival rate for female
patients with breast cancer has improved in the past 3 deca-
TABLE 2.
Estimated Number of US Cancer Survivors as of January 1, 2016, by Sex and Age at Prevalance
MALE AND FEMALE
All Ages, y
014
1519
2029
3039
4049
5059
6069
7079
80
des, because of improvements in treatment (ie, chemotherapy, hormone therapy, and targeted drugs) and earlier
detection through increased awareness and widespread use
of mammography.23 The 5-year, 10-year, and 15-year relative survival rates for breast cancer are 89%, 83%, and 78%,
respectively.
Cancer-related factors that influence survival include
stage, tumor grade and histology, hormone receptor status,
and human epidermal growth factor receptor 2 (HER2)
status. Sixty-one percent of breast cancers are diagnosed at
a localized stage, for which the 5-year relative survival rate
is 99%. However, compared with white women, black
women are less likely to be diagnosed with local stage breast
cancer (53% vs 62%) and have lower survival within each
stage.10 These differences are driven in part by socioeconomic factors and differences in comorbidities, less access
to and use of high-quality medical care among black
women, and biological differences in cancers (eg, higher
incidence of triple negative cancers among black
women).2426
MALE
FEMALE
NO.
PERCENT
CUMULATIVE
PERCENT
NO.
PERCENT
CUMULATIVE
PERCENT
NO.
PERCENT
15,533,220
65,190
47,180
187,490
408,790
958,600
2,389,670
4,141,950
4,011,790
3,322,560
<1
<1
1
3
6
15
27
26
21
<1
1
2
5
11
26
53
79
100
7,377,100
32,060
23,610
90,730
166,170
347,700
963,410
2,027,150
2,148,940
1,577,330
<1
<1
1
2
5
13
27
29
21
<1
1
2
4
9
22
49
79
100
8,156,120
33,130
23,570
96,760
242,620
610,900
1,426,260
2,114,800
1,862,850
1,745,230
<1
<1
1
3
7
17
26
23
21
Note: Percentages do not sum to 100% due to rounding.

Source: Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute.
274
CUMULATIVE
PERCENT
<1
1
2
5
12
30
56
79
100
FIGURE 2. Age Distribution of Survivors for Selected Cancer Types, January 1, 2016.
Percentages may not sum to 100% because of rounding.
Short-term and long-term health effects

Lymphedema of the arm occurs in 20% of women who
undergo axillary lymph node dissection and in about 6% of
women who undergo sentinel lymph node biopsy.27 Early
diagnosis of lymphedema is important for optimizing treatment and slowing progression.28 Some forms of cancer rehabilitation may reduce the risk and lessen the severity of this
condition.29,30
Other potential effects include numbness, tingling, or
tightness in the chest wall, arms, or shoulders following
surgery and/or radiation. Studies have shown that between
25% and 60% of women develop chronic pain after breast
cancer treatment, although it is usually not severe.3133 In
addition, treatment with chemotherapy can lead to
impaired fertility and premature menopause, which increase
the risk of osteoporosis.34 Chemotherapy with taxanes
often leads to neuropathy, which can persist long after
treatment ends.35 Anthracyclines and HER-2targeted
drugs can lead to cardiomyopathy and congestive heart failure.36 Treatment with aromatase inhibitors, which is generally reserved for postmenopausal women, can also cause
osteoporosis, as well as myalgia and arthralgia,37 whereas
tamoxifen treatment slightly increases the risk of endometrial cancer and thromboembolic disease.38 Hormonal treat-
ments may also cause menopausal symptoms, such as hot

flashes, night sweats, and atrophic vaginitis, which can lead
to dyspareunia.39 Breast cancer survivors may also experience
cognitive impairments and chronic fatigue.30,40
Cancers in Children and Adolescents

It is estimated that there are 65,190 cancer survivors aged
birth to 14 years (children) and 47,180 survivors aged 15 to
19 years (adolescents) living in the United States as of January 1, 2016. An additional 10,380 children aged birth to 14
years will be newly diagnosed in 2016. The 3 most commonly diagnosed cancers in children are leukemia (30%),
brain and central nervous system (CNS) tumors (26%,
including benign and borderline tumors), and soft tissue
sarcomas (7%), about one-half of which are rhabdomyosarcomas. Among adolescents, the most common cancers are
brain and CNS tumors (20%), followed by leukemia (14%)
and Hodgkin lymphoma (HL) (13%).1
Pediatric cancers are treated with a combination of therapies (surgery, radiation, chemotherapy, and targeted therapy) chosen based on the type and stage of cancer.
Treatment often occurs in specialized centers and is
275
FIGURE 3. Age Distribution of New Cases (%), Median Age at Diagnosis, Estimated Number of New Cases, and 5-year
Relative Survival by Cancer Type.
*The new case estimate includes other biliary cancers. Note that sites are ranked in order of the median age at diagnosis from oldest to youngest. Sources:
Age distribution based on 2011 to 2012 data from the North American Association of Central Cancer Registries and excludes Arkansas and Nevada. The
median age at diagnosis and 5-year relative survival are based on cases diagnosed during 2008 through 2012 and 2005 through 2011, respectively, from the
Surveillance, Epidemiology, and End Results 18 registries and were previously published in Howlader et al,10 and the 2016 estimated cases are from
Siegel et al.1
FIGURE 4. Female Breast Cancer Treatment Patterns (%) by Stage, 2013.

BCS indicates breast-conserving surgery; chemo, chemotherapy (includes immunotherapy and targeted therapy); RT, radiation therapy. Source: National Cancer
Data Base, 2013.
276
coordinated by a team of experts, including pediatric oncologists, surgeons and nurses, social workers, child life specialists, psychologists, and others.
Adolescents (ages 15-19 years) diagnosed with cancers
that are more common in childhood are usually most
appropriately treated at pediatric facilities or by pediatric
specialists. For example, studies have shown that pediatric
protocols result in better outcomes than adult protocols for
adolescent patients with acute lymphocytic leukemia
(ALL).41 In addition, childhood cancer centers are more
likely than adult cancer centers to offer adolescent patients
the opportunity to participate in clinical trials.42 For teen
patients with cancers that are more common among adults,
such as melanoma, testicular, and thyroid cancers, treatment
by adult-care specialists is more appropriate.43
The overall 5-year relative survival rate for all childhood
cancers (aged birth-14 years) combined has improved
markedly over the past 30 years, from 58% for patients
diagnosed between 1975 and 1977 to 83% for those diagnosed during 2005 through 2011, because of new and
improved treatments. Although there has been less dramatic
improvement in survival for adolescents, the current 5-year
relative survival rate (84%) is similar to that for children.10,44
However, survival rates vary considerably by cancer type.
For example, the 5-year survival rate during 2005 through
2011 was 89% for children and 76% for adolescents for
ALL, compared to 69% and 61%, respectively, for
osteosarcoma.10
Childhood cancer survivors may experience both long-term
(chronic) and late (occurring months or years after diagnosis or treatment) effects. Aggressive treatments used for
childhood cancers, especially in the 1970s and 1980s, have
resulted in several late effects, including increased risk of
subsequent neoplasms and cardiomyopathies. A recent
study found that 50% of childhood cancer survivors had
developed a severe or life-threatening chronic health condition by age 50 years.45 Among childhood cancer survivors
who were diagnosed and treated between 1962 and 2001,
65% of those who were exposed to pulmonary toxic cancer
treatments experienced pulmonary dysfunction, and 57% of
those who were exposed to potentially cardiotoxic therapies
experienced cardiac abnormalities.
Recent declines in late morbidity and mortality among
childhood cancer survivors are due in part to reduced use of
certain treatments, such as cranial radiation for ALL and
abdominal radiation for Wilms tumor.45 However, even
many newer, less toxic therapies increase the risk of serious
health conditions in long-term childhood cancer survivors.46
Cognitive impairment, which can vary in severity, affects up
to one-third of childhood cancer survivors.47 In addition,
surgery, radiation, and some chemotherapies affecting the
reproductive organs may cause infertility in both males and

females.48,49 The potential impact on fertility and plans for
fertility preservation should be discussed before commencing treatment. Treatment may delay maturation and normal
development in survivors and lead to negative body image
and psychological distress.50
Given these concerns, it is important that survivors of
pediatric cancers are monitored for long-term and late
effects as well as emotional and psychosocial concerns. The
Childrens Oncology Group, a National Cancer Institutesupported clinical trials group that cares for greater than
90% of US children and adolescents diagnosed with cancer,
has developed long-term follow-up guidelines for the
screening and management of late effects in survivors of
childhood cancer (survivorshipguidelines.org).
Colon and Rectum

It is estimated that, as of January 1, 2016, there are more
than 1.4 million men and women living in the United
States with a previous colorectal cancer diagnosis, and an
additional 134,490 cases will be diagnosed in 2016. Eightyfive percent of colorectal cancer survivors (about 1.2 million
men and women) are aged 60 years and older, while only
4% (60,610) are aged younger than 50 years (Fig. 2). The
median age at diagnosis for colorectal cancer is 66 years for
males and 70 years for females.10 Patients with rectal cancer
tend to be younger at diagnosis than those with colon
cancer (median age, 63 vs 70 years, respectively).
The majority of patients with stage I and II colon cancer
undergo partial or total colectomy alone (84%), while about
two-thirds of those with stage III disease (as well as some
with stage II disease) receive chemotherapy in addition to
colectomy to lower their risk of recurrence (Fig. 5). For
patients with rectal cancer, proctectomy or proctocolectomy
is the most common treatment (61%) for stage I disease,
and about one-half also receive radiation and/or chemotherapy (Fig. 6). Stage II and III rectal cancers are often
treated with neoadjuvant chemotherapy plus radiation. A
colostomy (usually temporary) is required during surgery
more often for patients with rectal cancer (29%) than for
those with colon cancer (12%).51 Chemotherapy is the
main treatment for stage IV rectal cancers. Growing numbers of targeted drugs are also available to treat metastatic
colorectal cancer.
The 5-year and 10-year relative survival rates for persons
with colorectal cancer are 65% and 58%, respectively.
When colorectal cancers are detected at a localized stage
(39% of cases), the 5-year relative survival rate is 90%.
277
FIGURE 5. Colon Cancer Treatment Patterns (%) by Stage, 2013.

Chemo indicates chemotherapy (includes immunotherapy and targeted therapy); RT, radiation therapy.
*A small number of these patients received RT. Source: National Cancer Data Base, 2013.
Neuropathy is a common side effect of chemotherapy regimens containing oxaliplatin.52 Chronic diarrhea occurs in
about one-half of colorectal cancer survivors.53 Bowel dysfunction (including increased stool frequency, incontinence,
radiation proctitis, and perianal irritation) is common among
rectal cancer survivors, especially those treated with pelvic
radiation.54,55 Survivors may also suffer from bladder dysfunction, sexual dysfunction, and negative body image.39,56,57
Referral to a trained ostomy therapist may benefit patients
with a colostomy who experience these issues.58 In addition,
cancer recurrence is not uncommon among colorectal survivors,59,60 who are also at increased risk of second primary
cancers of the colon and rectum and other cancer sites,
particularly those within the digestive system.61
most common types in adults, whereas ALL is most the

common among children and teens (Fig. 3).
There are 2 basic categories of lymphoma: Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). NHLs
can be further divided into indolent and aggressive categories, each of which includes many subtypes that progress
and respond to treatment differently. Prognosis and treatment depend on the stage and type of lymphoma. It is estimated that, as of January 1, 2016, there were 219,570 HL
survivors and 686,370 NHL survivors. About 8500 new
cases of HL and 72,580 new cases of NHL will be diagnosed in 2016. Although both HL and NHL occur in children and adults, the majority of HL cases (64%) are
diagnosed before age 50 years, whereas most NHL cases
(85%) occur in those aged 50 years and older (Fig. 3).
Leukemias and Lymphomas
Treatment and survival for the most common types of

leukemia and lymphoma
There are an estimated 407,950 leukemia survivors in the

United States, and an additional 60,140 people will be
diagnosed in 2016. Although leukemia is the most common type of cancer among children aged birth to 14 years,
the majority (92%) of patients with leukemia are diagnosed
at age 20 years and older.62 Acute myeloid leukemia
(AML) and chronic lymphocytic leukemia (CLL) are the
AML
Chemotherapy is the standard treatment for AML,
although many older adults, among whom the disease is
most common, are not able to tolerate the most aggressive
and potentially curative protocols. Patients may also
undergo allogeneic stem cell transplantation, and some
FIGURE 6. Rectal Cancer Treatment Patterns (%) by Stage, 2013.

Chemo indicates chemotherapy (includes immunotherapy and targeted therapy); RT, radiation therapy. Source: National Cancer Data Base, 2013.
278
receive radiation therapy, often as part of a conditioning

regimen before stem cell transplantation.
Approximately 60% to 85% of adults aged 60 years and
younger with AML can expect to attain complete remission
status after the first phase of treatment, and 35% to 40% of
patients in this age group will be cured.63,64 In contrast,
40% to 60% of patients aged older than 60 years will
achieve complete remission, and only 5% to 15% will be
cured. About 4% of AML cases occur in children and adolescents,62 for whom the prognosis is substantially better.
The 5-year relative survival rate for children and adolescents (aged birth-19 years) is 65% but declines to 50%,
32%, and 6% for patients aged 20 to 49 years, 50 to 64
years, and 65 years and older, respectively.
CML
Chronic myeloid leukemia (CML) is most common in
adults, and only 2% of cases are diagnosed in children and
adolescents.62 The cancer cells in CML contain a characteristic fusion gene, bcr-abl (breakpoint cluster regionAbelson), which is caused by a translocation of genetic
material between chromosomes 9 and 22, resulting in the
Philadelphia chromosome. Modern treatment of CML has
been transformed by tyrosine kinase inhibitors (TKIs)
aimed at the BCR-ABL protein, which induce remission
in most patients but must be taken indefinitely. Stem cell
transplantation may be used in younger patients and those
who become resistant to TKIs, whereas chemotherapy is
only used in TKI-resistant patients. Primarily because of
the discovery and widespread use of the BCR-ABL TKIs,
the 5-year survival rate for CML increased from 31% for
patients diagnosed during 1990 through 1992 to 63% for
those diagnosed during 2005 through 2011.10,65
ALL
More than one-half of ALL cases (56%) are diagnosed in
patients younger than 20 years. Chemotherapy is the standard treatment for ALL. About 20% to 30% of adult ALL
cases and <5% of childhood cases are Philadelphia
chromosome-positive and may benefit from the addition of
a BCR-ABL TKI to chemotherapy.66,67 More than 95% of
children and from 78% to 92% of adults with ALL attain
remission.68 Allogeneic stem cell transplantation is recommended for some patients who have high-risk disease characteristics and for those who relapse after remission or who
fail to achieve remission after successive courses of induction chemotherapy.
Survival rates for ALL have increased significantly over
the past 3 decades, particularly among children.10 Notably,
the black-white 5-year relative survival disparity in children
and adolescents with ALL has diminished from a 21percentage-point difference during 1980 through 1984
(49% vs 70%) to a 3-percentage-point difference during
2005 through 2011 (89% vs 92%).11 Survival declines with

increasing age at diagnosis, and the current 5-year survival
rate is 46% for patients aged 20 to 39 years, 30% for those
aged 40 to 64 years, and 15% for those aged 65 years and
older.
CLL
CLL is the most common type of leukemia in adults, and
95% of cases are diagnosed in individuals aged 50 years and
older (Fig. 3). Treatment is generally reserved for symptomatic patients or for those who have cytopenia or other
complications because the disease is slow-growing and
treatment is unlikely to result in a cure. Available treatments include chemotherapy, immunotherapy, targeted
therapy, radiation therapy, and splenectomy, but it is often
not clear whether these treatments extend survival.6971
The overall 5-year relative survival rate for CLL is 82%;
however, there is large variation in survival among individual patients, ranging from several months to a normal life
expectancy. About 5% to 10% of patients with CLL
develop diffuse large B-cell lymphoma (DLBCL), a process
known as Richter transformation.72
HL
There are 2 major types of HL. Classical HL (CHL) is the
most common and is characterized by the presence of
Reed-Sternberg cells. Nodular lymphocyte-predominant
HL (NLPHL), which is characterized by popcorn cells,
comprises only about 5% of cases.62 NLPHL is a more
indolent disease with a generally favorable prognosis.73
CHL is generally treated with multiagent chemotherapy
(88%), sometimes in combination with radiation therapy
(30% among chemotherapy recipients), although the use of
radiotherapy is declining.14 If these treatments are not
effective, stem cell transplantation or the targeted drug
brentuximab vedotin may be options. For patients with
NLPHL, radiation alone may be appropriate for early stage
disease. For those with later stage disease, chemotherapy
plus radiation as well as the monoclonal antibody rituximab
may be recommended.
The 5-year and 10-year survival rates for HL are 86%
and 80%, respectively. The 5-year survival rate is 94% for
NLPHL and 85% for CHL.
NHL
The most common types of NHL are DLBCL, representing 37% of cases, and follicular lymphoma, representing
20% of cases.62 Although DLBCLs grow quickly, most
patients with localized disease and about 50% of those with
advanced-stage disease are cured.74,75 In contrast, follicular
lymphomas tend to grow slowly and often do not require
treatment until symptoms develop, but many are not curable.76 Some cases of follicular lymphoma transform into
DLBCL.
279
The first course of treatment for all NHL subtypes combined is usually chemotherapy, either alone (58%) or in
combination with radiation (11%) (Fig. 7). Approximately
17% of patients receive no treatment. A monoclonal antibody like rituximab is often given along with chemotherapy
for B-cell lymphomas and for some T-cell lymphomas.
The 5-year survival rate is 86% for follicular lymphoma
and 61% for DLBCL; 10-year survival declines to 77% and
53%, respectively.
People treated for leukemia and lymphoma can experience
several significant long-term and late effects. Some leukemia and lymphoma survivors, such as those who undergo
stem cell transplantation, have problems with recurrent
infections and with anemia, which may require blood transfusions. Certain chemotherapy drugs, as well as high-dose
chemotherapy used for stem cell transplantation, can lead
to infertility. Allogeneic transplantation used to treat acute
leukemias can lead to chronic graft-versus-host disease,
which can cause skin changes, dry mucous membranes
(eyes, mouth, vagina), joint pain, weight loss, shortness of
breath, and fatigue.
Chest radiation for HL increases the risk for cardiac dysfunction as well as breast cancer among women who were
treated in childhood and adolescence. Patients with HL,
NHL, and ALL are commonly treated with anthracyclines,
which can also be cardiotoxic. In the past, some children
with ALL who were at increased risk for CNS relapse
received cranial radiation therapy. This treatment can cause
long-term cognitive deficits, and it is used less frequently
and at lower dosages today.77
Lung and Bronchus

It is estimated that there are 526,510 men and women living in the United States with a history of lung cancer, and
an additional 224,390 cases will be diagnosed in 2016. The
median age at diagnosis for lung cancer is 70 years.
Lung cancer is classified as small cell (13% of cases) or nonsmall cell (83%) for the purposes of treatment (3% of cases
in the SEER database lack information on histologic
type).10 Most patients with small cell lung cancer receive
chemotherapy.14 In addition, some patients are also treated
with thoracic radiation therapy. For stage I and II nonsmall
cell lung cancers (NSCLC), the majority of patients (69%)
undergo surgery, and about 25% of surgical cases also
receiving chemotherapy and/or radiation therapy (Fig. 8).
Most patients with stage III and IV NSCLC receive chemotherapy with or without radiation (53%). Targeted therapy
drugs, such as angiogenesis inhibitors, epidermal growth
factor receptor (EGFR) inhibitors, and anaplastic lym280
FIGURE 7. Non-Hodgkin Lymphoma Treatment Patterns (%),
2013.
phoma kinase (ALK) inhibitors, are also an important part

of the treatment for NSCLC. Recently, immunotherapy
drugs that act by targeting the programmed cell death
receptor on T cells have been approved to treat some types
of NSCLC.
The 1-year relative survival for lung cancer increased
from 34% during 1975 through 1977 to 45% during 2008
through 2011, largely because of improvements in surgical
techniques and chemoradiation. The majority of lung cancers (57%) are diagnosed at a distant stage, because early
disease is typically asymptomatic; only 16% of cases are
diagnosed at a local stage.10 The 5-year survival rate is 55%
for cases detected when the disease is still localized, 27%
for regional disease, and 4% for distant stage disease. The
5-year survival for small cell lung cancer (7%) is lower than
that for NSCLC (21%).
Many lung cancer survivors have impaired pulmonary function, although some may have had preexisting respiratory
problems.78 In some cases respiratory therapy and medications can improve fitness and allow survivors to resume normal daily activities. Treatment with EGFR inhibitors can
lead to a severe acneiform rash. Immunotherapy drugs used
in lung cancer treatment can lead to several immune mediated
toxicities, including pneumonitis, colitis, nephritis, and
endocrinopathy.
Lung cancer survivors who are current or former smokers
are at increased risk for subsequent smoking-related cancers, especially lung, head and neck, and esophageal, as well
as other smoking-related health problems. Survivors may
feel stigmatized because of the social perception that lung
cancer is a self-inflicted disease, which can be particularly
FIGURE 8. Nonsmall Cell Lung Cancer Treatment Patterns (%) by Stage, 2013.
difficult for those who never smoked.79 Data suggest that

there is a benefit to smoking cessation even after a lung
cancer diagnosis.80,81
Melanoma
It is estimated that there are more than 1.2 million melanoma survivors living in the United States, and an additional 76,380 people will be diagnosed in 2016. Sixty-three
percent of melanoma survivors are under the age of 70, and
17% are under the age of 50 (Fig. 2). Melanoma incidence
rates continue to increase in men but have recently stabilized in women.1 Women tend to be diagnosed at a
younger age than men (58 vs 65 years, respectively),10
reflecting differences in occupational and recreational exposure to ultraviolet radiation, as well as early detection;
women are more likely to be diagnosed at a localized stage,
86% versus 82% of men.
Surgery is the primary treatment for most melanomas.
Patients with stage III disease may be offered adjuvant
immunotherapy with interferon or the anticytotoxic Tlymphocyte-associated protein (anti-CTLA) antibody ipilimumab, although these treatments can have serious side
effects. Treatment for patients with stage IV melanoma has
changed in recent years and typically includes immunotherapy (ipilimumab, pembrolizumab, and nivolumab) or targeted therapy drugs, both of which have been shown to
extend survival.8284 BRAF (B-Raf proto-oncogene, serine/
threonine kinase) inhibitors have been shown to improve
survival for melanomas with the BRAF gene mutation,
which account for about one-half of all cases.8587 Almost
one-half (46%) of patients with stage IV disease who
receive either chemotherapy or immunotherapy also receive
radiation therapy.14
The 5-year and 10-year relative survival rates for persons
with melanoma are 92% and 89%, respectively. About 84%
of melanomas are diagnosed at a localized stage, for which
the 5-year survival rate is 98%.

Depending on the size and location of the melanoma,
removal of these cancers can be disfiguring. Male and
female melanoma survivors are nearly 13 and 16 times
more likely, respectively, than the general population to
develop additional melanomas because of skin type and
other genetic or behavioral risk factors.88 From 10% to 15%
of patients treated with ipilimumab experience serious
autoimmune-related side effects that sometimes can lead to
death.89 Autoimmune-related side effects occur less often
with pembrolizumab and nivolumab. Patients treated with
BRAF inhibitors have an increased risk of developing squamous cell skin carcinomas.
Prostate
It is estimated that there are more than 3.3 million men
living with prostate cancer in the United States, and an
additional 180,890 cases will be diagnosed in 2016. The
majority (64%) of prostate cancer survivors are over the age
of 70 years, and less than 1% are under age 50 years (Fig. 2).
The median age at diagnosis is 66 years (Fig. 3). Most prostate cancers in the United States are diagnosed by prostatespecific antigen (PSA) testing, although many expert
groups, including the American Cancer Society, have concluded that data on the efficacy of PSA screening are insufficient to recommend routine use of this test.90
Treatment options vary, depending on the extent of disease
and the risk of recurrence, as well as patient characteristics,
such as age and comorbidity, and personal preferences. Figure 9 shows primary treatment among men diagnosed during 2010 through 2012 based on SEER data [information
on the use of androgen deprivation therapy (ADT) is not
available] for all stages combined, although most (92%) of
cases are diagnosed at the localized stage. Men younger
than 65 years are most likely to be treated with radical prostatectomy (with or without radiation), whereas about onehalf of men 75 years or older do not undergo surgery or
radiation.
281
and diabetes.103106 Although some studies indicate an

increased risk of cardiovascular disease or death associated
with the use of hormone therapy, the evidence is inconsistent.104,105,107 Careful monitoring of cardiovascular risk
factors is recommended for men who have received
ADT.108,109
Testis
FIGURE 9. Prostate Cancer Treatment Patterns (%) by Age,
United States, 2010-2012.

RT indicates radiation therapy. Patients with missing treatment data were
excluded. Source: Surveillance, Epidemiology, and End Results (SEER) Program, SEER 18 Registries, 2010 to 2012.
Active surveillance rather than immediate treatment is a

reasonable and commonly recommended approach, especially for men who have less aggressive tumors, are older,
and/or have serious comorbid conditions.9193 ADT, chemotherapy, bone-directed therapy (such as zoledronic acid or
denosumab), radiation, or a combination of these treatments are used to treat more advanced disease. Newer
forms of hormone therapy, such as abiraterone and enzalutamide, have been approved in recent years to treat
advanced prostate cancer that is no longer responding to
traditional hormone therapy.9497
The 5-year relative survival rate approaches 100% for
patients with localized disease, but declines to 28% for
those diagnosed at a distant stage. The 5-year relative survival for all stages combined increased from 83% in in the
late 1980s to 99% in the most recent time period (20052011), primarily reflecting lead time and overdetection.
The 10-year and 15-year relative survival rates are 98% and
95%, respectively.
Surgery and radiotherapy for prostate cancer are associated
with risk of substantial physical impairments, including urinary incontinence, erectile dysfunction, and bowel complications.98101 In one long-term follow-up study, greater
than 95% of patients with prostate cancer who underwent
surgery or received radiation experienced some sexual dysfunction, and about 50% reported urinary or bowel
dysfunction.102 Patients receiving hormonal treatment
may experience loss of libido, hot flashes, night sweats, irritability, and breast development. In the long term,
ADT also increases the risk of osteoporosis, obesity,
282
It is estimated that there are 266,550 testicular cancer survivors in the United States, and an additional 8720 men
will be diagnosed in 2016. Testicular germ cell tumors
(TGCTs) account for approximately 97% of all testicular
cancers.62 The 2 main types of TGCTs are seminomas and
nonseminomas. Nonseminomas are more common, generally occur in men in their late teens to early 40s, and tend
to be more aggressive than seminomas. Seminomas are
slow-growing and are generally diagnosed in men in their
late 30s to early 50s.
Treatment of almost all TGCTs begins with orchiectomy.
While the most common treatment for stage I and II seminomas is surgery alone (46%), many surgical patients also
receive radiation (31%) or chemotherapy (22%) (Fig. 10).
Over the last decade, postsurgical active surveillance has
become an increasingly preferred management option for
patients with stage I seminomas, and long-term study results
support this treatment strategy.110 Stage III and IV seminomas are generally treated with surgery and chemotherapy
with or without radiation therapy (70%). Among patients
with stage I and II nonseminomas, approximately 20%
undergo retroperitoneal lymph node dissection, which is
recommended to reduce the likelihood of recurrence
(Fig. 11). Patients with stage III and IV nonseminomas are
treated with surgery and adjuvant chemotherapy, and some
require additional surgery after completion of
chemotherapy.
The 5-year, 10-year, and 15-year survival rates are all
approximately 95%. Most testicular cancers (68%) are diagnosed at a localized stage, for which the 5-year relative survival rate is 99%.
Although most men who have one healthy testicle produce
sufficient male hormones and sperm to continue sexual relations and father children, sperm banking is recommended
before treatment. Consultation about fertility risks before
treatment and referral for sperm banking as appropriate are
important in efforts to promote quality-of-life outcomes.
Retroperitoneal lymph node dissection can lead to retrograde ejaculation, making unassisted reproduction impossible. Men treated with chemotherapy have increased risks of
coronary artery disease as they age, so these patients and
FIGURE 10. Treatment Patterns (%) for Seminomatous Testicular Germ Cell Tumors by Stage, 2009 to 2013.
their physicians should be particularly mindful of risk factors like hyperlipidemia, hypertension, obesity, and smoking.111 Men who have bilateral tumors have both testes
removed and require lifelong testosterone supplementation.
Thyroid
It is estimated that there are 805,750 people living with a
previous thyroid cancer diagnosis in the United States, and
an additional 64,300 will be diagnosed in 2016. Thyroid
cancer is the most rapidly increasing cancer in the United
States1 and has been increasing worldwide over the past
few decades.112 Studies suggest that the rise is primarily
due to the increased incidental detection of indolent papillary tumors through widespread use of imaging.113 Accumulating awareness of this epidemic of diagnoses has
resulted in more conservative clinical practice guidelines
about when to biopsy and a subsequent stabilization of
overall incidence rates.114 However, increasing trends for
larger and follicular tumors indicate that risk factors may
also be contributing to a true increase in disease occurrence.115,116 The median age at diagnosis54 years for
males and 49 years for femalesis younger than that for
most other adult cancers (Fig. 3).

Most thyroid cancers are either papillary or follicular carcinomas, which are highly curable, but about 3% are
medullary or anaplastic carcinomas,10 which are more difficult to treat because they do not respond to radioactive
iodine treatment.117 These cancers also grow more quickly
and often have metastasized by the time they are
diagnosed.
The first choice of treatment in nearly all patients with
thyroid cancer is surgery, with most patients undergoing total
(86%) or partial (12%) thyroidectomy.14 About one-half of
surgically treated patients who have papillary or follicular
thyroid cancer receive radioactive iodine (I-131) after surgery
to destroy any remaining thyroid tissue and cancer.118 After
total thyroidectomy, thyroid hormone-replacement therapy
is required and is often prescribed in a dosage sufficient to
inhibit pituitary production of thyroid-stimulating hormone
to decrease the likelihood of recurrence.
Total thyroidectomy is the primary treatment for
patients with medullary thyroid cancer. When the tumor is
extensive or cannot be completely resected, radiation therapy may be given after surgery. Targeted drugs can be useful in treating metastatic disease. Anaplastic thyroid cancers
are often widespread and resistant to treatment; in selected
FIGURE 11. Treatment Patterns (%) for Nonseminomatous Testicular Germ Cell Tumors by Stage, 2009 to 2013.
Chemo indicates chemotherapy (includes immunotherapy and targeted therapy); RPLND, retroperitoneal lymph node dissection; RT, radiation therapy. Note
that a small proportion of patients (<1% of those with early stage disease and about 5% of those with late-stage disease) who underwent surgery also received
RT. Source: National Cancer Data Base, 2013.
283
patients, radiation therapy alone or in combination with

chemotherapy may be used.
The 5-year relative survival rate for patients with thyroid
cancer who were diagnosed during 2005 through 2011 is
98%,10 although survival varies by age at diagnosis, stage,
and histologic type. Notably, blacks are more likely to be
diagnosed at a localized stage compared with whites (78%
vs 68%, respectively) but have lower survival within each
stage and overall.10 For patients with medullary and anaplastic carcinomas, the 5-year relative survival rates are 88%
and 9%, respectively.11
Patients who undergo total thyroidectomy require thyroid
hormone-replacement therapy, and thyroid hormone levels
must be monitored to prevent hypothyroidism, which can
cause cold intolerance and weight gain. Surgical removal of
the thyroid gland can damage the underlying parathyroid
glands, leading to disorders of calcium metabolism. Surgery
can also damage nerves to the larynx and lead to voice
changes. Treatment with radioactive iodine can affect fertility and may be linked to an increased risk of leukemia.119
About 25% of medullary thyroid cancers occur as part of a
genetic syndrome (such as multiple endocrine neoplasia
[MEN] type 2), so these patients should be screened for
other cancers and referred for genetic counseling and possible testing.120
Urinary Bladder
It is estimated that there are 765,950 urinary bladder cancer
survivors living in the United States, and an additional
76,960 cases will be diagnosed in 2016. Bladder cancer incidence is about 4 times higher in men than in women.62
The median age at diagnosis is 73 years. More than 70% of
patients who have bladder cancer are diagnosed with
nonmuscle-invasive disease.11
For nonmuscle-invasive cancers, most patients are diagnosed and treated with transurethral resection of the bladder tumor (TURBT), which may be followed by
intravesical chemotherapy (22%) or biologic therapy with
bacillus Calmette-Guerin (29%).14 (The NCDB does not
distinguish between systemic and intravesical chemotherapy but, based on treatment guidelines, it is likely that virtually all chemotherapy is intravesical administration.)
Among patients with muscle-invasive disease, about
one-half undergo TURBT, and 39% undergo cystectomy,
with or without chemotherapy and/or radiation (Fig. 12).
TURBT followed by combined chemotherapy and
radiation therapy is as effective as cystectomy at preventing
recurrence in appropriately selected cases.121123
Chemotherapy is usually the first treatment for cancers that
284
FIGURE 12. Muscle-invasive Bladder Cancer Treatment Patterns (%), 2013.

Chemo indicates chemotherapy (includes immunotherapy and targeted therapy); RT, radiation therapy; TURBT, transurethral resection of the bladder
tumor. Source: National Cancer Data Base, 2013.
have metastasized, but other treatments might be used as

well.
For all stages combined, the 5-year relative survival rate
is 77%.10 Survival declines to 70% at 10 years and to 65% at
15 years after diagnosis. The 5-year relative survival rate for
in situ urinary bladder cancer, which accounts for 51% of
cases, is 96%.10 For the 35% of patients with invasive
tumors diagnosed at a localized stage, the 5-year survival
rate is 70% (81% for those with nonmuscle-invasive disease
and 47% for those with muscle-invasive disease).
Posttreatment surveillance is crucial given the high rate of
recurrence (estimates range from 50% to 90%).124,125 Surveillance can include screening for urine biomarkers and
cytology as well as cystoscopy. Patients who require
repeated bladder surgeries can end up with a small or
scarred bladder, which may lead to urinary frequency or
incontinence. Partial cystectomy results in a smaller bladder, sometimes causing the patient to have more frequent
urination. Patients undergoing cystectomy in which the
entire bladder is removed require urinary diversion with
either construction of a neobladder with urethral anastomosis or a urostomy. Those with a neobladder retain most of
their urinary continence after appropriate rehabilitation.126
However, creation of a neobladder remains much less common than urostomy (9% vs 91%), largely because of the
technical complexity of the procedure; its use is substantially higher at larger, higher volume hospitals.127 Younger,
healthier patients and those who are male are also more
likely to undergo the procedure.
FIGURE 13. Uterine Corpus Cancer Treatment Patterns (%) by Stage, 2013.
Uterine Corpus
There are an estimated 757,190 women living in the United
States with a previous diagnosis of uterine corpus cancer
and an additional 60,050 cases will be diagnosed in 2016.
Cancer of the uterine corpus is the second most prevalent
cancer among women after breast cancer. The median age
at diagnosis is 62 years (Fig. 3).
Surgery, consisting of hysterectomy (often including bilateral salpingo-oophorectomy) alone, is used to treat 69% of
patients with stage I and II disease, whereas 28% of women
receive radiation and/or chemotherapy in addition to surgery
(Fig. 13). Two-thirds of women with stage III and IV disease
undergo surgery followed by radiation and/or chemotherapy.
Clinical trials are currently assessing the most appropriate regimen of radiation and chemotherapy for women with metastatic or recurrent cancers.
The 5-year and 10-year relative survival rates for women
with uterine corpus cancer are 82% and 79%, respectively.
Most cancers (67%) are diagnosed at an early stage, usually
because of postmenopausal bleeding, for which the 5-year
survival rate is 95%. The overall 5-year survival for white
women (84%) is about 22 percentage points higher than
that for black women (62%).10
Any hysterectomy causes infertility. Bilateral oophorectomy
will cause menopause in premenopausal women, which can
lead to symptoms such as hot flashes, night sweats, atrophic
vaginitis, and osteoporosis. Long-term side effects of radiation therapy for uterine cancer can include bladder and
bowel dysfunction as well as atrophic vaginitis and stenosis.
Sexual problems are commonly reported among uterine
cancer survivors.128 Pelvic lymphadenectomy can lead to
lower extremity lymphedema, particularly for women who
also receive radiation.129
Quality of Life and Other Concerns in

Long-Term Survivorship
Although quality of life may decline considerably during
active cancer treatment and remain low for a short period
thereafter, many side effects are acute and short-lived, and the
majority of disease-free cancer survivors report good quality of
life 1 year posttreatment. The type and prevalence of longterm or late side effects vary with clinical factors (eg, cancer
type, treatment) and patient characteristics (eg, age, sex,
comorbidity). While emotional well-being for longer term
survivors (5 years) is generally comparable to that of individuals with no history of cancer, a significant number report
lower overall physical well-being than their peers.2,130 Many
survivors also suffer from a fear of recurrence and subsequent
primary cancers.131 Quality-of-life issues also encompass the
concerns of cancer caregivers, who provide substantial emotional and physical support to survivors and who frequently
report having unmet psychosocial and medical needs.132
There is increasing emphasis on improving cancer survivors overall well-being and quality of life through the
application of principles of disease self-management and
the promotion of healthy lifestyles, such as avoiding
tobacco, maintaining a healthy body weight, avoiding
intense ultraviolet radiation exposure, and being physically
active throughout life. Several practical interventions for
survivors addressing diet, weight, and physical activity
among cancer survivors have been developed and tested.133
In addition, support for smoking cessation and increased
access to cessation aids are essential, because approximately
10% of cancer survivors continue to smoke even up to 9
years after diagnosis.134 Younger cancer survivors in particular have been shown to have a higher prevalence of smoking after diagnosis than the general population.135
It is therefore important for providers to understand the
unique medical and psychosocial needs of survivors as well
as their caregivers and to be aware of resources that can
assist in navigating the various phases of cancer survivorship. The American College of Surgeons CoC has issued
285
standards for quality, patient-centered cancer care that

include recommendations for patient navigation, palliative
care, distress management, and survivorship care planning.136 The Alliance for Quality Psychosocial Cancer
Care, a coalition of professional and advocacy organizations, including the American Cancer Society, formed to
advance these recommendations and issued a comprehensive resource guide, which is available to assist CoCaccredited facilities in meeting the new standards.137 Several organizations, including the American Cancer Society,30,58,109,138 have begun to produce guidelines to assist
primary care and other survivorship physicians in the provision of care for people with a history of cancer. The ACS
guidelines focus on comprehensive survivorship care,
including ongoing surveillance and cancer screening, support for health behavior changes, and the assessment and
management of the long-term and late effects of cancer and
its treatment.
Conclusion
In this article, we document the continued growth of the
cancer survivor population in the United States and
describe patterns of treatment and common side effects
across the most prevalent cancers. Despite increasing
awareness of survivorship issues and the resiliency of cancer
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Author Contributions: Kimberly D. Miller: Conceptualization, formal analysis, investigation, writingoriginal draft, writingreview and editing, and project administration. Rebecca L. Siegel: Conceptualization, methodology,
writingreview and editing, and supervision. Chun Chieh Lin: Conceptualization, formal analysis, and writingreview and editing. Angela Mariotto:
Methodology, formal analysis, and investigation. Joan L. Kramer: Conceptualization and writingoriginal draft. Julia Rowland: Conceptualization, writing
original draft, and writingreview and editing. Kevin Stein: Writingreview
and editing. Rick Alteri: Writingreview and editing. Ahmedin Jemal:
Writingreview and editing and supervision.
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